Health

In addition to other issues connected with the EU referendum (e.g. EU immigration, EU benefits tourism and housing crisis and the EU), Britain is currently hotly debating the crisis in the health system or the National Health Service (NHS). It is not unusual for segments of the British media to lead with headlines such as “Migrants are pushing NHS to breaking point,” claiming that the NHS has been left “on its knees” by “uncontrolled migration” from the EU which has merged with the theme of “health tourism” or the practice of travelling abroad in order to receive medical treatment.

Prominent members of the Leave EU campaign, such as Michael Howard and others in the Vote Leave campaign have said: “We will be talking a lot about the NHS in this campaign because we believe that a leave vote is vital if we are to protect the NHS for future generations.”Priti Patel, the Employment Minister, claims that the health service is under threat because of EU membership: “Current levels of migration are causing unsustainable pressures on our public services and we can see that the NHS is creaking under the strain.”

The implication is that EU migration / benefit tourism is at the root of the problems of the NHS. So this post addresses the nature of the UK health crisis and the extent to which it is attributable to the EU migration and health tourism.

Challenges every which way you look

The National Health Service (NHS) is the largest and oldest single-payer healthcare system in the world. It is primarily funded through the general taxation system that is overseen by the Department of Health. The NHS is built upon the principle of comprehensive health service provision based on clinical need, not ability to pay. The NHS provides healthcare to every legal resident of the UK, with most services free at the point of use.

When created after WW-II, the NHS was the pride and joy of the pioneering British welfare state and served as a model for many other countries. But the fact is that the NHS has been in crisis for decades going back to at least the 1980s. As Britons are well aware, wave upon wave of health reforms have sought to cure its ills yet the NHS remains as sick as ever. The starting point in the health debate is to acknowledge that the problems with the health system predate the influx of EU migrants to the UKwhich started in earnest in earnest 2004 and continues to this day. The NHS’ problems did not begin with EU immigrant and will not end if migration were suddenly to end, regardless of whether migrants originate from the EU (less than half of UK immigration) or elsewhere (Britons returning home, Commonwealth, students, etc. – more than half of the immigration).

The second point is to recognise that the challenges facing the NHS are many and varied, not least connected with an ageing population and the impact of modern diseases such as diabetes, obesity, cancer, etc., combined with escalating costs of procedures, medication and so on.

The health professionals are in the best position to assess the issues and whether those issues are connected with migration or not. In a recent publication “Challenges facing the NHS in England: a guide for MPs and Peers”, the NHS Confederation (representing over 500 NHS organisations that commission and provide health services, including hospitals, community and mental health providers, ambulance trusts and independent sector organisations providing NHS care) set out the main health challenges facing the health system. These are illustrated in the diagram below.

Neither immigration in general nor EU immigration specifically figures as a health challenge. There is no reference to NHS creaking / breaking / lack of sustainability due to migratory pressures. This is hardly surprising since all the evidence is that EU immigrants tending to be younger, better educated and in better health than the average Briton in the labour force. We tend to consume disproportionate amounts of health services as babies/children and as pensioners, especially after the age of 75. Young adults – the typical EU migrants – put relatively few pressures on the health system.

Rather, the Call for Action focuses on areas about which there is little controversy among the 500 health professionals in the NHS Confederation. They stress the need for stability if the NHS is to tackle its challenges (endless reforms); the need to increase staff (too few); the necessity for social care funding for people with long-term illnesses; the need to make mental health services available and accessible, etc. The most critical issue by far is the finance challenge; this is the underlying reason for the continuing problems faced by the NHS. The point to note is that the UK is exclusively responsible for the resources that it devotes (or not) to the NHS. No amount of finger-pointing in the general direction of the EU will alter this particular fact.

Furthermore, the NHS funding challenge is nothing new: it predates and supersedes other factors such as EU migration. This is the fundamental reason why the NHS has been gradually overtaken by other countries, as illustrated in comparative research among OECD countries highlighted in the Table below.

The UK’s performance compared with OECD countries highlights the NHS’ fall from grace. The UK ranks:

19th in terms of health expenditure per capita;

24th in terms of doctors per capita;

19th in terms of nurses per capita;

26th in terms of hospital beds per capita;

29th in terms of Magnetic Resonance Imaging (MRI) units per capita;

30th in terms of Computer Tomography (CT) scanners per capita.

Some countries, such as Germany, have even higher levels of EU immigration than the UK yet it comfortably outperform the UK in terms of the selected health indicators. Money, or rather the lack of it, is clearly an important reason for why the NHS is in the state that it is.

The UK’s austerity measures, which have been in place since 2009, included severe budget constraints with zero growth in health spending per person in real terms. On a per capita basis and as a share of GDP, health spending in the UK is slightly below the OECD average. Lack of financial capacity is clearly not the issue. Rather the UK government chooses to prioritize other public expenditure, such as defence, over the heath system. Furthermore, the situation is set to deteriorate: the NHS Confederation estimates that the gap between increasing demand for care and the funding available will be at least £30 billion by 2020. The key point is that other economies choose to put more resources into their health systems than Britain. The state of the NHS, by and large, reflects this particular policy prioritisation. Transferring the entire net budget that Britain spent in 2015 on the EU into the NHS, namely £8.5 billion (2014) would not make that much of a difference in the projected NHS deficit of £30 billion in 2020 for England alone. The Vote Leave campaign misleads in suggesting that cancelling one (EU contribution) will solve the problem of the other (NHS crisis).

EU health tourism: where’s the beef?

Health provision is clearly a national issue – the EU has no direct powers in this area except to support the common market. The Government’s audit of EU powers (the so-called balance of competence review) also covered health area and its official report concluded that: “…the UK Government believes that the current balance of competence is broadly appropriate.” It also noted that: “Industry were generally very supportive of the current position regarding competence.” It concluded that: “Evidence suggested that free movement of persons brings benefits for the UK health sector and for patients, but not without risk.”

There are “risks” perceived in some quarters, such as the EU’s Working Time Directive (WTD), which limits work to a maximum 48-hour week and lays down minimum requirements for rest periods and annual leave. But can critics really sustain the argument that the health profession should work longer hours than other professions? Most people would not agree. When it comes to a critical matter of life and death, most people would want a doctor / nurse / surgeon who is neither exhausted nor overworked (we all recall UK health workers, especially junior doctors, having to work absurd and dangerous numbers of hours in the past) when attending to their health needs. The WTD applies to all 28 countries and all professions; I see no reason for making an exception for the UK or for the NHS, though this does not preclude the possibility of fine-tuning the WTD.

There is also freedom of movement of doctors and nurses from across the EU working in the health system in the UK. This is actually a very good thing for the NHS, as acknowledged by the government’s official report: “In terms of health professionals, there has been a very positive impact for the NHS as 10% of NHS staff are from European Economic Area (EEA) countries, without whom there could be staff shortages.” For example, the Royal College of Midwives, has stressed that Britain would be hard-pressed to find enough midwives and nurses trained in the UK to replace the 33,000 from other EU countries who currently work in the NHS.

It is not only an issue of the damage that staff shortages might cause in such a sensitive area as the heath sector. The issue which those interested in improving the health system should be focusing on is exactly why Britain continues to be completely incapable of training a sufficient number of its own health professionals. I recall nurses and midwives being sourced from Ireland before the EU and the rest of the world became the NHS’s recruitment pool for health workers. No open-minded individual can fail to see Britain’s gain in this form of EU migration. If anything, other nations might well criticise the NHS’s beggar-thy-neighbour recruitment strategy (i.e. a policy by which one country attempts to remedy its economic problems by means that tend to worsen the economic problems of other countries) which basically mops-up experienced doctors, nurses, midwives, surgeons, etc. which other countries have paid to educate and train.

There is also the Cross Border Healthcare Directive which allows individuals to purchase health care and treatment from a provider in another Member State. This is supported by the health industry in the UK since it offers them the prospect of widening the sources of income by attracting EU patients and using excess capacity in the health system, for example in specialist areas such as diagnosis and treatment of rare diseases. Furthermore, under the current NHS arrangements, patients in one location of the UK are not free to seek treatment in another part where waiting times/lists may be shorter. However, the Cross Border Healthcare Directive enables them to seek treatment in other EU countries if they wish. This is a good thing: it allows patients to control their own health needs. Something that puts power in people’s hands over vast bureaucracies, for that is exactly what the NHS is, must be a good thing.

EU-related health costs: Britain only recovers 23% of what it could claim back

In 2014 an official report (Quantitative Assessment of Visitor and Migrant Use of the NHS in England), showed that EU (27 countries) and EEA (3 other countries) visitors and non-permanent residents cost the NHS an estimated £305 million, of which £220m is recoverable by England under the European Health Insurance Card (EHIC) scheme. Every EEA country issues EHIC cards to their citizens, thus enabling them to receive healthcare whilst on a temporary visit to another EEA country on the same basis that is provided to its own residents. People go on holiday in the EU/EEA knowing that if they fall ill or have an accident they will be able to access health care without the need for separate insurance. This saves time, effort and money for all and is widely considered a good thing.

Department of Health data for 2012-13 show that only about £50m was recovered from the EEA countries compared with the £173m that the England pays for British visitors to EEA countries. This means that the NHS / Department of Health are not claiming as much of the money that they are eligible to receive from the EEA countries as they could.

Some forget that this is not a one way street; it is not only EU nationals that come to the UK and use health service here. Britons also make a good deal of use of the health services in other EEA countries and the costs more or less balance out: £220m worth of health services received by EEA people in England, compared with £173m worth of services received by people from England in EEA countries.

The low percentage of recovery (22.7%) is due to one reason and oner reason only: NHS inefficiency, which is an issue for the UK to rectify. Why should Britain need over a decade to set-up a working reciprocal health cost management system when the other 27 nations have long ago managed to do so? It has been argued that there is a lack of knowledge among NHS healthcare professionals as to who is eligible for free treatment. Can this really be so fiendishly complicated as to systematically defeat the British health care system with its new generation of sharp suited, MBA educated management? Surely it is not like expecting the NHS to crack the health equivalent of the Enigma Code.

Rather than voting to Leave the EU for a problem that can only be pinned on Britain itself, it might be more effective to set-up a system to check if an individual is from the EEA and train healthcare professionals to recoup the costs of EU patients, as Britain is fully entitled (but fails systematically) to do.

EU-related health costs: instead of 0.18% of the NHS budget in England, it costs 0.26%

Interestingly but not surprisingly the actual health costs of EEA migrants are very low, despite all the emotive talk of “EU migrants / freedom of movement pushing NHS to breaking point” and “NHS is creaking under the strain of immigrants” emanating from the Vote Leave EU group such as Priti Patel and others. The annual NHS budget in England was worth £116 billion in 2015/6, so EEA migrants used-up 0.26% of the annual NHS budget (£305 million). When the costs that could have been recovered from EEA countries are taken into consideration (on the assumption that the NHS ever gets its act together), the percentage would drop to 0.18% (£220 million). There would appear to be vastly bigger fish to fry when it comes to saving costs in the British health system.

When this analysis is extended from England to the UK, the same health competences report noted that in 2012/13 the UK paid a net £805 million to EEA countries to cover the healthcare costs of Britons, especially pensioners, living in other countries. This sum illustrates just how many UK citizens benefit from the EU health provisions.

The health competences report also stressed that: “… many more UK pensioners choose to live in other EEA countries than pensioners from those EEA countries who live here. Using Spain as an example, approximately 400,000 British pensioners reside there at any one time. For a great majority of these, the fact that the UK covers their healthcare is of great benefit. It should also be noted that, had those citizens remained in this country, the UK would be meeting the costs of their NHS care in the usual way and in some Member States the average cost of healthcare can be lower.”

In other words not only do more British pensioners benefit from the system than EU pensioners gain from using the NHS but it would cost the NHS more to provide health care to those 400,000 Britons currently living in Spain (and potentially many others, since there were about 1.4 million Britons living in the EU) if they came back. The Vote Leave EU campaign would find it hard to swallow the point that EU health provisions may actually be saving British taxpayers money (and/or that the savings are being recycled for the benefit of the health of the people in Britain).

It should be noted that the NHS (Charges to Overseas Visitors) Regulations Act of 2015 requires hospitals to charge overseas visitors (not ordinarily resident) for the NHS services that they provide in a hospital or provided outside by staff employed by a hospital. GP services and services provided outside hospitals are not chargeable. So it would appear that Britain is well on the way to meeting the public concerns about the costs of health for visitors, whether from the EU or elsewhere.

EU health tourism: much ado about very little

The UK’s competences review concluded that, on balance, the EU’s engagement in the health sphere is appropriate and noted the major advantages of EU health directives, including the IHIC card, the number of EU educated nurses and doctors working in the UK and the capacity to access European level health services. There are real benefits for health institutions and citizens across EU countries.

In terms of the major health challenges facing the UK in the future, the 500 NHS Consortium health institutions did not identify immigrants as an issue: money or rather the lack of it is the key issue in Britain. The evidence is that EU/EEA citizens use the NHS intensively less than native Britons. In any case, Britons make extensive of health services in EEA countries, especially those that retire in Spain, France and elsewhere.

The EU introduced health transfer arrangements to ensure that each EEA nation pays according to the health services absorbed by their nationals. This is fair but it is up to each country to introduce the necessary systems and procedures. After a decade, the NHS is still unable of charge its share, which means that instead of EU nationals costing the NHS 0.18% of its annual budget, it actually costs 0.26% in England.

Boris Johnson, Michael Gove and other Vote Leave campaigners may insist that the “billions spent on the UK’s EU budget contribution to be spent on the NHS.” That is fair enough but let us not pretend that this will solve the problems in the health system at a stroke. Even if the GBP 8.5 billion net EU contribution were poured in its entirety into the NHS tomorrow, nothing would change fundamentally because the financial need is much greater than this contribution. Can it realistically be argued that EU migration / health tourism is pushing the NHS to breaking point, especially when large numbers of Britons and British pensioners living in the EU are actually reducing the costs to the NHS since the costs of health provision in Spain and elsewhere are lower than they would have been in the UK?

I don’t think this is such a bad health deal for Britain and is not a sufficient reason for voting to leave the EU in the forthcoming referendum.

Is the EU responsible for the state of British health system: the EU ensures that all EU citizens have access to health services in all countries at no extra cost or hassle.

Is the British government responsible for the state of British heath system: the UK is 100% responsible for national health provision and the health budget. The UK chooses to invest a smaller amount on health than other countries and this is the root cause of the health problems. Pumping Britain’s entire EU annual contribution in the NHS will not change the fundamentals of the health system, though it would certainly be helpful.

Should I vote to leave the EU because of EU health tourism: EU nationals make less use of the NHS than do native Britons. Also, there are more retired Britons living in EU countries and making use of other EU health systems than there are EU nationals living in the UK. Both save the NHS money and/or allow resources to be focused on health services in Britain.

A humorous but apt Danish proverb is that “Prediction is difficult, especially when dealing with the future.” As the politicians finally stop pushing the merits of their policies and the British voters reflect on which way to cast their vote on 07 May 2015 general election, I will hazard some predictions about the likely general election result, as well as the political priorities that are likely to be pursued in the next few years in Britain. Most if not all of the predictions will probably come back to haunt me, but here goes nothing…

And the winner is…

My main prediction is that the Conservatives will win more seats than any other political party, even if the polls suggest that the election might be a close call. I also predict that the Conservatives will gain an overall majority, rather than a hung parliament. The main reasons for this prediction are all to do with Labour, rather than the Conservatives or their policy initiatives:

Labour is going to be decimated in Scotland and the other political parties will have almost no influence there. The clear winner is going to be the Scottish National Party (SNP) and with this development, the dynamics of Westminster-based politics will change dramatically, especially for the Labour Party.

The British public, including many traditional Labour voters, remain extremely sceptical about the final Blair / Brown years, which they blame a lot of the issues confronting society, not least being drawn into recent wars, immigration trends and the state of the economy. Many voters will switch to the SNP in Scotland and the Conservatives and/or UKIP in England.

Large segments of the general public neither relate to nor trust either Ed Miliband or any of the current crop of Labour leaders. In this respect, I cannot help but experience a sense of déjà vu in respect to the Michael Foot / Neil Kinnock era which bodes ill for the Labour Party.

The Conservatives will profit from the above and will form the next government. This is particularly the case because the UKIP vote, though significantly understated in the opinion polls, nevertheless does not seem to be as much of a threat to the Conservatives as previously anticipated. This is as much to do with the current electoral system as UKIP’s almost wilful self-destruction through incompetence combined with persistent gaffes by its candidates that undermine the message that it is neither anti-immigration nor racist. Despite it all, UKIP retains strong support in parts of England.

My other two predictions concern the issue of austerity and its implications on British society, as well as the future of Britain in the European Union.

EU Referendum: plus ça change…

Regarding the in-out EU referendum scheduled for 2017, the Conservative Party will finally have to break cover and clarify whether it belongs to the yes or no camp. If the Conservatives are able to form a majority Government, as the traditional party of business, it will ultimately side with remaining in the EU, whatever the pressures of UKIP or the antics of its noisy Eurosceptic wing. After all, the Conservative policy of offering an EU referendum in 2017 was a strategic move calculated to defang UKIP and yet placate the more rabid anti-EU Tories; it was not a decision to leave the EU per se.

Their shambolic position on the EU reflects the fact that David Cameron and other senior members of the Conservative Party, on balance, favour remaining in the EU. The political price to be paid for campaigning to remain in the EU is that this will prove to be the second and final term of office for David Cameron as the Prime Minister and possibly as an MP. The SNP, LibDems and Labour will campaign in favour of remaining in the EU. Moreover, the business sector will make its views in an increasingly vocal and forcible manner and the wider pro-EU voice will be more pronounced than has been the case hitherto. Unlike the present time where few speak up, others, such as art, culture and sport personalities will do likewise as a means of counteracting what will remain, in the main, a strongly anti-EU media.

Should a coalition Government arise, the LibDems would have to perform much better than anticipated to have a chance of running the country. The other possible coalition partner to the Conservatives, despite protestations to the contrary, is UKIP. If the latter coalition government were to emerge, the political price to be paid to UKIP will be a Conservatives campaign to leave the EU and to hold the in/out referendum in 2016, rather than 2017. A combination of the Conservatives and UKIP running to leave the EU would be a disaster for Britain (as well as the remaining EU countries already battered by the travails of Greece and holding the Eurozone together), which would be very hard to counteract, especially with the majority of the British media supporting their position. Britain would come to regret the likely outcome in the medium to long-term.

Under any scenario involving a referendum, the EU will have to show flexibility and do whatever it takes in to facilitate the UK remaining in the EU. As I have previously argued, there will not be fundamental EU treaty amendments for the sake of keeping Britain in the EU boat, such as a reform of the freedom of movement or the other three fundamental freedoms of movement, namely of capital, services (which is extremely underdeveloped) and goods. However, the EC and the EU will be more flexible in areas such as benefit entitlement in the EU area, which in any case is almost entirely determined by nation states, rather than EU directives and regulations.

If the referendum were to be held today, I believe the outcome would be an outright rejection of the EU. The great majority of British media is extremely anti-EU and anti-immigration and would contribute to a no vote. However, there could be up to two years for business, society and voters to reflect on the not insignificant advantages of being part of the EU, as well as the potential consequences of Britain going it alone in an increasingly globalised world. A re-orientation towards the old and new Commonwealth and North America is no longer adequate to guarantee current, let alone future prosperity. An emphasis on trade at the exclusion of everything else that the EU brings simply does not cut the mustard in the modern era, where problems such as environmental issues and tax agreements require regional or global responses, rather than national ones. Turning our back on 27 other next door neighbours around us in Europe is simply not sustainable in an economic, social, political or any other sense.

I retain great faith in the capacity of the British public to eventually do the right thing. The following Winston Churchill quotation springs readily to mind: “The Americans will always do the right thing… after they’ve exhausted all the alternatives.” Substitute “Brits” for “Americans” and you get the gist of what I mean. The outcome of the EU referendum will be a narrow “yes” majority to remain in the EU. The alternative does not bear thinking about.

Austerity ad nauseam

The last prediction is that the squeeze on the public sector is set to continue for the next few years and it will further transform Britain and its welfare state, resulting in a more divided and fragmented society. There will be a repeat of the pattern set in the previous Parliament, namely a dramatic public expenditure squeeze in the first two years, followed by a gradual let-up as the term of office peters out and politicians look to be re-elected.

The Conservative Party does not deny that further cuts in the order of GBP 12 billion in social expenditure are in the pipeline, even if it is rather coy about how exactly this will be achieved. If the last Parliament was anything to go by, the brunt of the cuts will continue to be borne by the more vulnerable members of society, while corporations and the wealthy are spared.

There will continue to be a lot of talk about benefit scroungers (British and EU) to justify the cuts which will fall disproportionately on the working poor and non-working segments of British society. The austerity agenda continues to offer handy political cover for a significant reduction in the size of the state and the social and welfare infrastructure, including local government. This is set to continue, spreading more deeply to areas such as police, judiciary, military, etc. since the other options have been largely exhausted. The alternative would be to put the squeeze (e.g. means testing benefits of various sorts, higher taxes, etc.) on the middle classes, the retired and the wealthy; this will not happen if the Conservatives hope to be re-elected thereafter.

In the meantime, some of the things that Britons are most concerned about such a shelter (sufficient, affordable and good quality housing), health (NHS, access and quality) and education (primary, secondary and tertiary) will continue to experience gradual deterioration. These are simply not great priorities for the Conservatives. Their traditional supporters are capable of by-passing any current or future shortcomings in state provision and directly accessing the highest quality services that money can provide, though the phenomenon of the “squeezed middle” will ensure that political capital and financial resources will still be devoted to these fundamental themes.

Instead, the (EU and non-EU) migrants will continue to act as the lightning rod for people’s frustration with a slowly crumbling system, while those that have been running these very systems for decades or generations are largely spared the British citzens’ ire. After all, if housing is unaffordable and private renting is insecure, the normal response in a modern wealthy country would be to stimulate significant additional supply and/or ensure that appropriate protections are enacted. This will not happen. If there are not enough school places or hospital beds, then public investment should deliver greater supply while still maintaining standards. This is highly unlikely to happen either. Yet it is Westminster that is responsible for recognising, responding to and securing these changes over the medium term, not individual citizens looking to access these services, regardless of their nationality, race or creed.

We shall know the result of the general election soon enough. I sincerely hope that most of the above predictions prove to be wrong, in which case I will gladly eat my hat.

A Historic Turning Point Coming Up?

British voters are weighing up their options, but a strong element of anti-EU sentiment can be detected. The General Election scheduled for 05 May 2015 may well be turn out to be historic. If the Conservative Party wins, it is committed to holding a straight in/out referendum in 2017 about whether Britain is to remain in the EU or not. Previous posts have discussed the role of the eurosceptic Conservative wing and the role played by the Ukip party in the hardening Conservative and Labour Party stance in relation to the EU and EU-related immigration. Previous posts have also discussed a growing anti-Euro and anti-Islam sentiment in Germany, though it is materially different and not as pervasive as in the UK. No obvious anti-EU sentiment can be detected, which is why this post focuses mainly on Britain.

A reading of opinion polls illustrates that the balance of British public opinion, which has never exactly been EUphoric since joining in 1973, appears to be turning stringently EUrosceptic. The common assumption among quite a few politicians and a large segment of the media seems to be that life would become instantly better if only Britain would jettison membership of the EU, regain “control over its borders”, thus stopping “uncontrolled” migration along with excessive “interference” from Brussels in British affairs. But is this really the case? How much would actually change overnight, as far as the voters’ priorities are concerned?

Voter Priorities (2010-2015)

With the British general election not so far away, it is worth asking: just how much would actually change in people’s lives if the UK were to leave EU in terms of immediately improving life in Britain, based on the issues that matter to voters? To address this thought experiment, I have used the latest Ipsos MORI poll which asks about the top concerns of British voters.

In January 2015 four issues predominated in terms what is important to voters, namely healthcare (almost half), economy (one-third) followed by asylum and immigration (27%) and education/schools (20%). Europe/EU as an issue is on par with unemployment, which at present is a pretty low rate in the UK (less than 10% note it as being important). A further five issues are of some importance in terms of voting intentions (benefits, taxation, housing, foreign affairs and pensions).

Table 1 shows some change since 2010, but the top four priorities have been fairly consistent. What is noticeable, however, is that whereas economy and education have not changed, both health and immigration have risen significantly in importance to British voters since 2010. Perhaps surprisingly, housing is increasing in importance but remains a secondary priority for British voters.

Voter Priorities and UK vs. EU Responsibilities

On the basis of the voter’s priorities, it is worth asking the question: what exactly are the responsibilities of the British Government and what is affected by the EU? On the basis of this question, it is possible to assess what might change for Britons.

Below I discuss these issues briefly, focusing first on the top four voter priorities:

Health: The Department of Health is entirely responsible for the NHS in terms of budget, priorities, reforms, etc. The main EU influence is in enabling the citizens of the EU-28 to be fully covered when they go to other EU countries without the need for additional health insurance for work, holidays, study, etc. It also allows people to choose where they wish to be treated, if the services are better or waiting lists are shorter. Health Tourism is an issue concerning non-EU citizens, rather than for EU ones. Nothing dramatic would change tomorrow, if the UK were to leave the EU in terms of quality of care, waiting lists, response rates or any of the other key issues of concern to the British voter. If anything, choice is likely to be reduced and extra costs incurred when British citizens travel to the EU. In terms of EU residents living in the UK and their use of the health service, not much would change. If they are working, they are also paying for the NHS through their National Insurance contributions. Otherwise, they would have to insure themselves privately and still have access to health in Britain. The exception would be if the UK chooses to deport, something that is barely imaginable. Verdict: no change. There are no magical solutions to the problems of the health service in Britain. The trends are neither recent nor connected with membership of the EU.

Economy: the UK is entirely in charge of its macro- and micro-economic destiny, since it is not part of the euro and thus not affected by the eurozone rules. The UK can affect its interest rates and implement quantitative easing to its heart’s content. The Stability and Growth Pact does have requirements, such as no budget deficits greater than 3% of GDP, no public debt exceeding 60% of GDP without diminishing by 5% per year on average over 3 years. Verdict: nothing would change. The UK and many other countries have greatly exceeded these limits at a time of serious economic and financial concerns. Britain is 100% in charge of its destiny, unlike Greece, Spain, etc. The Chancellor has already set in train further drastic reductions in public expenditure in the next period of Government. There is nothing about the programme of austerity that the British Government can pin on the EU, which is probably why this has not been tried, unlike for example Greece.

Asylum/immigration: as I have previously discussed, there are three elements here. Firstly, the UK is entirely in charge of its asylum policy and can choose who to let in and who to keep out. The same applies to non-EU immigration, which Britain is entirely in charge of. These elements comprised over 68% of immigration (together with Britons returning to the UK). The EU cannot and does not interfere with this but the balance (32%) is EU migrants. Many international companies are based in Britain that require access to the global pool of human resources to maintain their standards and profitability. On balance, basing a decision to leave the EU because of the freedom of movement of people principle and perceptions of “uncontrolled immigration” in the last decade does not appear to be justified. The unemployment rate remains at 5.8% (compared with 6.5% in Germany and 11.4% in the EU), despite a long period of intense economic and financial crisis. A critical issue that affects voter sentiment is net wages, which is determined by the companies located in Britain, as well as the public employers. If Britain were to stop EU and any other form of immigration (it is doubtful that employers would welcome this) the perceived pressures on health, housing and social services would not change since most EU immigrants would presumably remain. The exception is if such a police were to be combined with (forced) repatriation, which is unimaginable at the present time. If so, in theory Britain would have to make allowance for the 1.3 million Britons in other EU countries to return from EU countries to the UK. Verdict: possible short-term gain but likely long-term loss. The change would affect 32% of Immigration (2012 data) at the very most, but asylum and immigration would not end. There would only be perceptible changes, if a policy of terminating EU immigration were to be combined with deportation. I cannot imagine the average British voter wanting this or the consequences of enforcing such a policy.

Education/schools: this is entirely the responsibility of the UK and the pressures have been decades in the making. The issue that the EU has concentrated on is harmonizing qualifications and certification to ensure greater scope for freedom of movement of workers. This is advantageous for Britons as well as for others. Verdict: no change. The children of EU migrants make-up a small percentage of all children in schools across the country. If their parents are working here, they are entitled to study in Britain unless the Government and the British electorate wishes to evoke the deportation route.

So in terms of the most important issues to UK voters, there is not a huge amount of immediate gain from Brexit, based on the top four voter priorities. I am not even going to discuss the possible losses which would be the consequence of gaining control over EU immigration. Britain is already in charge of two of the three key elements of immigration, which makes up the majority of immigration. It is an island, which gives it more protection than others in the era of globalisation. The fear that there is uncontrolled immigration from the EU is overdone. When the economic downturn started, many EU migrants simply left the UK of their own accord and the migratory pattern turned towards Germany instead, the only EU country experiencing strong economic growth. When the UK economy started growing again in mid-2014, the immigration trend started reversing (though probably influenced by the A2 countries,namely Romania and Bulgaria). In any case, if the unemployment rate is 5.8% and decreasing, it is worth asking the question: who is employing the EU migrants and benefiting from their contribution to the economy, to tax inflows and to company profits? Might the answer be Britons and Britain? If the real issue is decreasing net wages and benefits in Britain, the question is who is gaining from this development? Might the answer be certain segments of British society?

Below I address the remaining voter priorities:

Europe/EU: The issue which the EU insist on is that the freedom of movement of people (as well as goods, services, capital) be maintained, allowing all EU citizens to travel for tourism, study, work and retirement purposes. Many, if not most Britons, enjoy some or all of these freedoms in one way or another. 1.3 million Briton live in other EU countries, and a large number travel, work, study, invest (e.g. second homes and pension funds) or retire in EU countries. This is something which is currently taken for granted at present. I believe the loss will be felt much more rapidly and keenly than most British voters may realise.

Unemployment: leaving the EU might result in less European migrants, but it would not put an end to EU immigration or lead to zero unemployment. British-based enterprises compete globally for many skills essential to maintain productivity and innovation. I doubt that there would be a significant reduction in qualified labour coming from the EU.It is not certain that the agricultural, tourism, hospitality, etc. businesses would be able to satisfy their needs simply from UK-based sources. There might be a reduction in less qualified labour and thus in unemployment but this is unlikely to be more one or two percentage points and will lead to other pressures. Verdict: possible short term gain but likely long term loss.

Benefits: very few EU migrants claim benefits. Immigrants were 45% less likely to receive state benefits or tax credits than UK natives during 2000-2011. They are also less likely to live in social housing than the UK born population. EU migrants of working age who are not students, not in employment and receive some kind of state benefit, amount to 39,000 or less than 1% of all foreign nationals in the UK and 1% of all EU nationals in the UK. Recent analysis of 23 out of 27 EU countries shows that there are at least 30,000 Britons claiming unemployment benefit in countries around the EU. In other words 2.5% of Britons in other EU countries are claiming unemployment benefits, roughly the same as EU nationals doing the same in Britain. The numbers are tiny: the political and media coverage of this issue is completely disproportionate. If this is the case, an even smaller sub-set of them are living in Britain for benefit tourism/abuse purposes. Verdict: no change (but one less emotive topic for certain parts of the media and politicians to bang their biased drum about).

Taxation: the UK is in entirely in charge of all its taxes, including Corporate Income Tax, Income Tax, Capital Gains Tax and VAT. Verdict: no change.

Housing: The UK is entirely in charge of its housing policy, construction, planning system, etc. There would be fewer EU immigrants, which might affect the housing situation in terms of rent levels and house prices. However, this would only be a marginal effect since the trend in housing supply, demand and pricing is a long term trend of over 30 years and any nationality is able to buy property in Britain. I have already referred to the fact that fewer recent immigrants claim benefits and live in social housing than the UK born population. Verdict: no change. I have written the first of my blog posts comparing the British and German housing systems to illustrate aspects of this point.

Foreign affairs: in terms of foreign affairs this role is, to some extent, coordinated with the High Representative of the Union for Foreign Affairs and Security Policy for specific issues. In the main, each EU nation does its own thing and Britain is no different.

Pensions: the UK is entirely in charge of the retirement age, contributions, qualifying years, minimum state pension pensions, etc. The EU facilitates freedom of movement of people and capital, so develops rules to ensure that if people work in different countries, that their contributions are acknowledged and count towards their overall pension entitlement. Furthermore, it seeks to ensure, under the same two freedoms, that Britons and others can receive their state pension in any of the EU-28 countries without suffering from arbitrary reductions, cancellations, fees, etc. Since many Britons enjoy their retirement in the sun and have bought second homes in other EU countries (rather more than is the case in terms of EU nationals buying properties in the UK), it would appear that to be well worth remaining in the EU.

EUroscepticism: much ado about nothing?

Ultimately, it is up for each voter to assess their personal gain or loss from staying in or leaving the EU. Based on the analysis above, the anti-EU sentiment is much ado about nothing, as far as the most important issues to voters are concerned, except for the freedom of movement of people. The EU has helped to secure so many rights and opportunities across all 28 nations that it is hard to imagine life without them. It is not simply that not much would change overnight. A moment of reflection on what would be rolled back as a result of leaving the EU, should show just how much we perceive as being normal and do not even actively consider. The fact is that we usually do not miss that which we take for granted… until it is no longer there.

New AngloDeutsch™ Blog Launched

Today, the AngloDeutsch™ Blog was launched. The main reason is that Britain and Germany are countries that are absolutely critical to the future of Europe and the European Union. Yet, there is currently a gap in terms of comparing and contrasting the two countries in terms of various dimensions, such as economics, housing, health, etc. within the overarching context of the EU.

It was not always so. In the same year that Britain joined the European Economic Community in 1973, the Anglo German Foundation (AGF) was established in recognition of the fact that the Germany and Britain could learn a good deal from each other, not least to improve mutual knowledge between the two countries and deepen understanding of modern society and its problems. The AGF undertook policy-oriented comparative research on the Britain, Germany and what is now the European Union (EU). It was valuable to compare and contrast countries that were not only the two largest in the EU, which also exhibit rather different social, political and economic traditions. They are two of the largest EU trading and exporting nations, the people respect each other and, despite the differences, or perhaps because of them, they can learn from each other’s ways of doing things.

In 2009 the Trustees decided to abolish the AGF, the main argument being: “… other organisations at both national and European levels are now carrying this work forward, and the need for a specific institution for this purpose is no longer so compelling.” (Anglo-German Foundation for the Study of Industrial Society,p.3).

British and German Comparisons Growing in Importance

I disagree with this conclusion. Some 40 years on, the reality is that the need for comparative analysis and discussion in relation to Britain, Germany and EU is greater than ever before and it is far from obvious which other institutions are carrying this work forward. I believe that the last Trustees of the AGF would probably be astounded at how dramatically things have evolved since their decision to end the institution.

A number of momentous developments are affecting the socio-economic dynamic in Europe:

The recession that started in 2009 has morphed into full-blown global financial and economic crises. The sovereign debt and the commercial banking crisis drag on and the prospect of deflation still looms large in Europe and elsewhere.

The Euro and the significant political and financial reform efforts connected with ensuring that it is kept alive has resulted in enormous fissures arising between Britain, Germany and the EU countries. These tensions are, if anything, increasing over time.

The political strains of keeping the Euro (and thus the EU) together, not least through various forms of austerity, have taken a massive toll on the credibility of the EU as well as the level of cooperation and trust between nation states, not least the German-British-French axis. This applies doubly so to the so-called „PIIGS“ (Portugal, Italy, Ireland, Greece and Spain) and the north Europeans, especially Germany, Holland, Austria, Finland, etc.

The UK and DE play a critical role in the future of the EU. Germany has become the undisputed albeit reluctant European hegemon, though the jury is still out as to how long this status will last. The decisions and even ruminations of Europe’s preeminent politician, Angela Merkel, reverberate throughout the EU. The same cannot be said of David Cameron (and still less François Hollande) to the same extent. Still, the UK’s role in EU, influential though diminished, remains critical to the future of the EU (independent Sterling, monetary and fiscal policy, insistence on EU reform and devolving powers to the nation state, challenge to the freedom of movement principle, possible in/out referendum on whether to remain in the EU in 2017, etc.).

These stresses and strains are part and parcel of what has become a full-blown crisis of the legitimacy of the “European Project”, as understood since it was formed in 1951 by the Treaty of Rome. A process whose ambition was to “make war not only unthinkable but materially impossible” (The Shuman Declaration, 9 May 1950) was not and could never have anything short of an economic, social and political project, even if the discourse was principally economic.

This ambition was not merely a Franco-German idea. Immediately after WWII Sir Winston Churchill was one of the first to call for a “United States of Europe” (“We must build a kind of United States of Europe. In this way only will hundreds of millions of toilers be able to regain the simple joys and hopes which make life worth living. ” 1946, p.1). The ambitions of the European Project have always been understood in its wider sense by its founder members, not least Germany, because of its particular historical specificities. However, this ambition was and remains almost entirely an economic or trade issue in pragmatic Britain.

Longstanding concerns about the legitimacy of the EU, the steady erosion of the powers of the nation state (contrary to the principle of „subsidiarity“), the implications of principle of freedom of movement and indeed of the limits to the notion of „ever closer union“ in the EU have been forced to the foreground by the Euro crisis. These issues must be debated and tackled to maintain legitimacy with the people as well as the governments of all 28 EU nation states.

Britain and Germany at the leading edge of the EU

In this context, the British and German electorates have a critical role to play in the future of their respective countries, as well as that of the “European project”. They are at the nexus of the most important debates connected with the great issues confronting Europe, not least:

The future of the Euro and the EU (e.g. EU reform and in/out referendum in 2017).

The advent of anti-EU / Euro parties (e.g. the Ukip and AfD).

The solutions to the recession / depression, austerity and falling standards of living.

The debates on the future of housing, education, poverty, migration, health, ageing, etc.

But also the more fun things in life, such as sport and traditions such as Christmas.

Through the AngloDeutsch™ Blog, launched today, focuses mainly but not exclusively on Britain, Germany and the EU, it is hoped that a contribution can be made not only to better understanding in general but also to possible economic and social policy solutions and recommendations. This would be in keeping with the tradition of the now defunct AGF, even if the focus of a blog cannot be on rigorous academic research per se.

Focusing on the British and German perspectives has gained in salience. The target group of this blog is not the academic community, interest groups or indeed the politicians, though it is hoped that they too will get involved and/or be influenced by the AngloDeutsch™ Blog. The target group is anyone who has enough humility to be willing to learn about alternative ways of doing things, discuss different views and maybe implement some of the ideas, taking into consideration the uniqueness and specificity of every nation, region and locality. This aim is illustrated in the Box below.

The AngloDeutsch™ Blog aims to contribute to the policy process in Britain, Germany and the EU more generally by raising comparative economic, social and political issues and by stimulating an exchange of knowledge, views and experience between informed citizens in the two countries, as well as the EU.

To kick off the blog, the first few themes covered by the AngloDeutsch™ Blog will include the following: